Anatomy & Physiology I/II · practice question

A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to musculoskeletal structure and mobility. Assessment data include the client develops redness and warmth at an IV insertion site. Which action should the nurse take first?

Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026anatomy-physiology

Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.Offer a warm blanket and reschedule assessment until after lunch.Complete all remaining scheduled tasks before reassessing the client.Tell the client symptoms are expected and avoid notifying the health care team.

Answer and explanation

Correct answer

A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Why

NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.

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A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to musculoskeletal structure and mobility. Assessment data include the client develops redness and warmth at an IV insertion site. Which action should the nurse take first?

Correct answer

Why

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